How does long‐term care impact the psychological wellbeing of older adults in different care policy contexts in the Netherlands?

Abstract Receipt of long‐term care (LTC) is generally associated with worse psychological wellbeing for community‐dwelling older adults. In addition to objective features of care use (e.g. formal vs. informal care), the subjective evaluation of care provision in terms of perceived sufficiency might be particularly predictive of one's wellbeing but is seldomly considered in the literature. Substantial changes in the availability of long‐term care in past decades raise the question to what extent these effects, if present, are consistent over historic time. The present study, therefore, aims at better understanding the associations between types of LTC use and perceived care sufficiency on psychological wellbeing in a changing LTC context in the Netherlands. Data from the Longitudinal Aging Study Amsterdam (LASA) were used from three points in time: 1998 (N = 582), 2008 (N = 459) and 2018 (N = 415). At each wave, participants were between 75 and 85 years of age and living independently. The results show that after adjusting for age, gender, education and health, using formal LTC had a negative effect on depressive symptoms only in 2018, but that this effect was not significantly worse compared to previous cohorts. Perceived care sufficiency was consistently negatively associated with depressive symptoms in all three points in time. This suggests that despite a less generous Dutch LTC system, psychological wellbeing among LTC users remains stable. Perceiving care provision as sufficient, however, can help older adults maintain psychological wellbeing and should be considered by researchers and policymakers that aim to improve care recipients’ wellbeing.


| INTRODUC TI ON
When age-related health impairments emerge and managing daily lives becomes difficult, maintaining psychological wellbeing can become challenging for older adults. As a response, they might choose to acquire assistance in the form of long-term care (LTC, assistance in personal or household activities due to the care recipient's healthrelated inability to perform these tasks). However, this can lead to an undesirable dependency on others (Fine & Glendinning, 2005;Stewart & McVittie, 2011), and as result, LTC recipients might struggle to maintain their psychological wellbeing (PWB), i.e. to retain a positive affective state of mind. This is indicated by the prevalence of depressive symptoms, which indicate affective problems (e.g. worrying, sleeplessness) and are often prevalent in LTC recipients (Pot et al., 2005). However, having unmet care needs (Pepin et al., 2017) and receiving insufficient care (Broese van Groenou, 2020) can be similarly detrimental to one's PWB, which highlights the importance of the subjective evaluation of LTC.
Both the use of various types of care and its perceived sufficiency may differ with the specifics of the LTC context, which includes the allocation, accessibility, and adequacy of publicly provided care. As a result of the rising demand for LTC, for example, budget-cuts were introduced in many countries that limit the use of such care (Colombo et al., 2011;Spasova et al., 2018). This may have led to more older adults perceiving their care provision as insufficient and, consequently, experiencing worse PWB. At the same time, policy measures are also aimed at and providing care that is more efficient and closer to recipients' needs (Janssen, Jongen, & Schroder-Back, 2016). An open question is to what extent the importance of care use and its perceived sufficiency for wellbeing has remained stable in the light of these changes. Sufficient care provision likely remains equally beneficial but acquiring adequate LTC that allows maintenance of PWB might have become more challenging. The aim of the present study, therefore, is to investigate the robustness of the relationships between LTC use, its perceived sufficiency and psychological wellbeing over historic time. In order to capture these trends, home-dwelling older adults' (aged 75 to 85) types of LTC use, perceived care sufficiency and PWB are compared across three points in historical time (1998, 2008 and 2018), in which Dutch LTC policies greatly differed from one another. The knowledge gained from this present study allows conclusions about the universality of this relationship by taking different LTC contexts into account. This knowledge is also valuable for policymakers aiming at identifying effective measures to promote the wellbeing of older care recipients.

| The effect of types of LTC use on psychological wellbeing
When individuals with health impairments receive LTC, they become dependent on others. As having a sense of control over one's life is critical for maintaining wellbeing in later life (De Quadros-Wander et al., 2014), losing this sense of control can feel undesirable (Fine & Glendinning, 2005;Stewart & McVittie, 2011) and lead to emotional distress (Newsom & Schulz, 1998), thus compromising PWB. In addition, when care recipients feel they are placing a burden on others (McPherson et al., 2011), this can also lead to depressive symptoms, further compromising their PWB (Cukrowicz et al., 2011). So, the use of LTC is generally associated with worse PWB (Pot et al., 2005).
One of the crucial factors in the impact of LTC use on PWB is the source that provides LTC. As informal, formal and privately paid care impose different restrictions on care recipients, their perceived control likely varies as a result, inducing differences in PWB between care recipients. When receiving formal care, the recipient becomes dependent on governmental regulations. Consequently, his or her options regarding the amount and frequency of LTC as well as the person that provides LTC are limited as these choices are determined by home-care providers. Even if changes in the care arrangement are possible, formal care recipients often struggle with the necessary administrative procedures (Zuurmond & de Boer, 2020) and therefore often choose to retain the existing arrangement (Marangos et al., 2018). Consequently, Pepin et al. (2017) found an elevated prevalence of depressive symptoms in recipients of formal care and mention losses of independence as likely causes.
In contrast, if care recipients buy LTC services with their own financial means (privately paid care) instead of receiving publicly funded formal care, they are able to decide when and how care is provided, often in direct negotiation with the care provider. In case of dissatisfaction, they can turn to another care provider without excessive administrative procedures. This provides LTC recipients with more control over the care arrangement, which might be one of the reasons for the higher psychological wellbeing among recipients of privately paid care (Broese van Groenou, 2020).
Receiving only informal care differs from formal and privately paid care arrangements: The care providers, in most cases spouses or children, already have an existing informal and often affective What is known about this topic?
• Formal care use has been associated with worse psychological wellbeing.
• Unmet care needs have been associated with worse psychological wellbeing.
• Recent reforms in LTC systems resulted in less use of informal and formal care.

What this paper adds?
• Formal care use has a comparable negative effect on psychological wellbeing in 1998, 2008 and 2018.
• Perceived care sufficiency is highly and positively associated with psychological wellbeing.
• Perceiving care as sufficient has become less important for psychological wellbeing.
relationship with the recipient. They can discuss the nature of care provision personally and independently of the regulations of professional care, leaving the care recipient more in control. However, recipients of informal care might struggle with placing a high burden on caregivers, in particular on filial caregivers who often have to combine care responsibilities with occupational and family responsibilities. Although spousal care comes more naturally and expected, the care recipient may also be aware that their spouses provide many hours of care and feel overburdened (Juntunen et al., 2018;Pinquart & Sörsensen, 2011). Due to concerns about overburdening their loved ones, care recipients often refuse to ask them for assistance (Bredewold et al., 2020) or experience poor PWB when using informal care.
In summary, we expect that receiving formal care is most detrimental to one's PWB, followed by non-spousal informal care and then by spousal care, while we expect care received from privately paid caregivers to be the least detrimental (Hypothesis 1).

| The effect of perceived sufficiency on psychological wellbeing
If care provision is perceived as insufficient, recipients likely struggle with activities of daily living (Na & Streim, 2017). Recipients value the support that enables them to, e.g., eat or shower as frequently as they desire (Komisar et al., 2005), and that provides them with a feeling of safety and attentiveness (De São José et al., 2016). Daily hassles that might arise if these needs are not met can have a detrimental impact on wellbeing (Landreville & Vézina, 1992). The link between perceived sufficiency and caregiving is also acknowledged by recipients, as 94% of institutionalised LTC recipients in a recent Dutch evaluation have indicated that the care they receive contributes to their wellbeing (Zuurmond & de Boer, 2020). We, therefore, expect that perceived care sufficiency has a positive impact on PWB (hypothesis 2).

| Changes over time
The relationship between LTC use, care sufficiency and PWB might have changed as a result of the substantial policy changes in the Netherlands from a generous LTC provision in the late nineties, to de-institutionalisation in the mid-2000s, and the substantial reorganisation of the LTC system since 2015.
In the late nineties, long-term care was covered by the Dutch Exceptional Medical Expenses Act (AWBZ) compulsory insurance against the risk of long-term care. LTC provision was universal and generous (Kraus et al., 2010) the number of beds in nursing homes was among the highest within EU countries (OECD, 2021a), but LTC at home was also provided generously. Thus, access to LTC was selfevident for those that needed assistance.
However, Dutch LTC expenditure was also far above the EU average (Eurostat, 2021). Therefore, during the following decade, de-institutionalisation policies were implemented to contain the increasing costs of LTC (De Meijer et al., 2015). Older adults were expected to stay at home as long as possible, which led to a decrease in the number of LTC beds per 1000 over 65-year-olds from 81.4 in 199865-year-olds from 81.4 in to 70.1 in 200865-year-olds from 81.4 in (OECD, 2021a and an expansion of home-care provision (da Roit, 2012). During the early and mid-2000s, policies were implemented that aimed at incentivising time-efficient LTC provision by care providers, but also at giving clients more choice in arranging LTC according to their preferences . More focus was also placed on family-and communal care responsibilities, evident by formally requiring co-residing family members to provide informal care since 2003 and shifting LTC responsibilities from the national level to municipalities with the 2007 Social Support Act (Da Roit, 2012).
These policy trends were reinforced by the fundamental reorganisation of the LTC system in 2015. The AWBZ was abolished and in part replaced by the Long-Term Care Act, which limited the eligibility for residential care to the most severe cases needing 24/7 care. This increased the demand for care at home and the ability to arrange that locally. Also, the Social Support Act was extended and more LTC services were now provided by municipalities (Janssen et al., 2016). Despite the aim to arrange care more at home for the ageing population, the number of over 65-year-olds that received publicly provided care at home decreased drastically from 383,207 in 2014 to 261,905 in 2015 (OECD, 2021b).
Thus, the situation for those in need of LTC has changed substantially over the past three decades: LTC resources are scarcer, which not only reduces older adults' access to LTC but also impacts the experience of those that receive LTC. During the 2000s, policy changes might have successfully attenuated some of the potential negative consequences for older adults' PWB. Policies that improve client choice, such as the personal budget, were positively received (Knijn & Verhagen, 2007), and the expansion of home-care is in line with older adults' preference to remain living independently. However, the reduction of formal home-care after 2015 might be particularly detrimental to older adults' PWB, as they may struggle to receive sufficient and adequate assistance. Concerns have indeed been raised that turning to informal care use is a result of having no other options rather than a result of changing norms towards social responsibility (Oudijk et al., 2011). Furthermore, substituting formal with informal care might be inadequate to meet recipient's care demands (Bonsang, 2009).
Policy changes aiming at improving efficiency and client choice might attenuate some of these negative effects, but critical evaluations of the reform also called into question whether these policy goals are met (Alders & Schut, 2019;Van Ginneken & Kroneman, 2015;Maarse & Jeurissen, 2016). The potential benefits of these policy changes might also become exhausted: While older adults might appreciate incremental changes towards more client choice, this might be perceived as burdensome when LTC is difficult to acquire but recipients are still expected to take responsibility for arranging the care they need.
We, therefore, expect that the association between LTC use and PWB became more negative over time for those receiving nonspousal informal, privately paid, and formal care, but less so for those that receive spousal care (hypothesis 3a). For formal care, this might be attributed primarily to increasing quality problems, while non-spousal care and privately paid care use might be increasingly forced due to the lack of formal care. In contrast, perceiving care as insufficient is likely similarly problematic across cohorts as it always indicates that important LTC needs are not met. We, therefore, expect that the positive effect of perceiving LTC provision as sufficient remains robust over time (hypothesis 3b).

| Other predictors of wellbeing
There are several other factors that are associated with both LTC use and PWB and can be more or less prevalent in a 75-85-year-old cohort. First, LTC use is primarily a result of health impairments (Andersen & Newman, 2005), while better physical health (Steptoe et al., 2015) and cognitive functioning (Llewellyn et al., 2008) are both associated with higher PWB. Furthermore, those with higher education report higher wellbeing compared to the lower educated (Navarro-Carrillo et al., 2020) and also use LTC differently: they use less informal and formal care, but more privately paid care (Abbing et al., 2021). Given that recent cohorts of 75-85-year-olds may suffer less from severe health impairments (Verropoulou & Tsimbos, 2017) and are higher educated than their peers in earlier cohorts (Abbing et al., 2021), we control for these variables in our analyses.

| Participants
For this study, data from the Longitudinal Aging Study Amsterdam

| Outcome
Psychological wellbeing was indicated by measuring depressive symptoms, using the Center for Epidemiologic Studies Depression scale (Radloff, 1977). The scale consists of 20 statements about emotional states during the past week that participants could agree or disagree with. There were four possible answers, ranging from 'rarely or never' (0 Points) to 'mostly or always' (3 points). An example of a statement is 'Last week I felt that everything I did costed me strength'. The score was created by adding up all points to create a scale from 0 to 60, where a higher score indicated more depressive symptoms. The use of privately paid care could be indicated as a separate category. Receiving care from a spouse was also an option, but we decided to use partner status instead, as having a partner is assumed to be more important for PWB than receiving care from the spouse.

| Independent variables
This information was combined to create five groups that reflect different caregiving situations: Those that have no partner and receive no care (1), those that have a partner and receive possibly care from any other source (2), those that have no partner and receive formal care with or without other informal care (3), those that have no partner and receive non-spousal informal care only, without formal care (4), and those that have no partner and receive privately paid care, but no formal or informal care (5). These exclusive categories were chosen to clearly distinguish the groups in their impact on PWB, including potential beneficial effects of having a partner.
Care sufficiency was measured for all participants, independent of whether they receive LTC or from which source they receive it.
Participants were asked to indicate whether they think that the care they receive overall is sufficient and could choose between the options 'Yes', 'It is acceptable ' and 'No'. Only the first answer indicated sufficient care provision, resulting in a binary variable.

| Control variables
Physical functioning was measured by six questions about the difficulty of daily activities based on Katz et al. (1963): Walking upstairs and downstairs, using public transport, cutting toenails, dressing and undressing, sitting down and standing up and walking outside for 5 min.
Responses that indicated the difficulty of each task were measured on a 5-point scale: (1) No, I cannot [perform this task] (2) Only with help, (3) Yes, with much difficulty, (4) Yes, with some difficulty, (5) Yes, without difficulty. The physical functioning scale was created by adding the item scores to create a scale from 6 (poor) to 30 (good functioning). Cognitive functioning was measured using the Mini-Mental State Examination (Folstein et al., 1975). It consists of 23 items from seven categories. Each item had a maximum score of either 1, 3 or 5, resulting in a scale from 0 (poor) to 30 (good functioning). Education was measured by asking participants to indicate the highest level of education from a list of nine options which were then recoded to three education levels: Low (elementary school or no education), medium (lower voca-

tional, intermediate education or intermediate vocational education)
and high (secondary school, higher vocational education, college, or university). Gender (1 = female) and age (in years) were also included.

| Analysis
First, descriptive statistics were included to provide an overview of sample characteristics in all three observations. Overall differences between the five care groups were analysed using ANOVAs and chisquare tests. Post-hoc tests that compare each group to all other groups combined were also included. Subsequently, the effects of types of LTC use (hypothesis 1) and perceived care sufficiency (hypothesis 2) on PWB were analysed with stepwise linear regression analysis for each observation (1998, 2008 and 2018) separately. Age and gender were included as controls in every model. In the first step, the LTC use variable was included as a predictor using simple contrasts, with the first group (no partner and no LTC use) as the reference category.
In the second step, care sufficiency was included in the model and in the final step, education, physical and cognitive health were included.
Hypotheses 1 and 2 were only tested with the final model. The stepwise approach aims at providing better insight into the explanatory effect of perceived care sufficiency and other predictors of wellbeing.
To test hypothesis 3, the full regression model was compared between the three cohorts using multigroup analysis using local estimation. The package lavaan, version 0.0.6-6 for the statistical environment R was used (Rosseel, 2011). The model comparison was made for each independent variable between the free model and a constrained model in which that predictor was constrained.
Significant differences between the effects of LTC use and care sufficiency on depressive symptoms (hypothesis 3) indicated that their effects on wellbeing have changed over time.

| Differences between the three periods
Differences in LTC use between observations were observed for all sources of LTC (see Table 1). For formal care, it differed significantly between all three cohorts, with the percentage of users decreasing over time. The percentage of privately paid care users was lower in 2008 compared to 1998, χ 2 = 8.610, p < .01, but did not significantly differ in 2018 compared to other cohorts. The percentage of non-spousal informal care users was significantly lower in 2018 compared to 1998, χ 2 = 6.702, p < .01. Finally, the percentage that has a partner was higher in 2018 compared to 1998, χ 2 = 9.869,   Note: *p < .05, **p < .01, ***p < .001.

TA B L E 4 (A)
The effects of long-term care use and perceived care sufficiency on depressive symptoms cognitive health, and gender distribution

| Main analyses
The first step of the linear regression analysis (see Table 4

| DISCUSSION
The present paper investigated the impact of LTC use and the perceived sufficiency of LTC provision on the psychological wellbeing of older adults in the Netherlands in three points in time (1998, 2008, and 2018 whereas formal care use decreased (see Table 1). This also implies that those who are unable to buy LTC might be disadvantaged in this regard.
Differences in the composition of the three samples also have to be taken into consideration. Residential care has become more limited due to reforms in particularly after 2015, and the group using this type of care was not included in this study. Thus, some particularly disadvantaged individuals that would have been admitted to nursing homes in the previous periods and therefore not eligible for this study might have been included in the 2018 sample. As descriptive statistics showed, the group of formal care recipients in 2018 is indeed smaller, but more disadvantaged in terms of health and PWB.
Other unmeasured characteristics of this group might therefore also affect the results (e.g. a genetic predisposition for depressive symptoms need it most or spread it more evenly among more LTC recipients (Rostgaard & Szebehely, 2012). Understanding how these different policy strategies impact not only care use but also perceived care sufficiency might help to choose adequate strategies to promote care sufficiency. As this study has shown, the subjective evaluation of LTC is important for maintaining PWB and should therefore be taken into consideration as much as possible to achieve the goal of providing sufficient and adequate care to everyone in need.

S TATEM ENT O F E TH I C A L A PPROVA L
The LASA Steering Group has reviewed and approved the request for data to ensure that proposals do not violate privacy regulations and are in keeping with informed consent that is provided by all LASA participants.

ACK N OWLED G EM ENTS
The Longitudinal Aging Study Amsterdam is supported by a grant from the Netherlands Ministry of Health, Welfare and Sport, Directorate of Long-Term Care.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.

AUTH O R CO NTR I B UTI O N S
Jens Abbing: Literature review, writing of the theoretical framework and discussion, data preparation and analyses.
Marjolein Broese van Groenou and Bianca Suanet: Design of the study, Feedback for revision and changes to text, advice for methodological approach, contribution of ideas.

DATA AVA I L A B I L I T Y S TAT E M E N T
LASA data are available for research. The LASA Steering Group has adopted a policy of sharing data with interested researchers for specific research questions on aging-related issues. To obtain data, researchers need to submit an analysis proposal that is evaluated by the LASA Steering Group. Data are available for investigation under the condition that results of analyses will be made available to the research community through scientific reports or research papers, regardless of the results of the study. More information on data requests can be found on the LASA website: www.lasa-vu.nl.